Basics Of Root Canal Treatment

By:
Dr. Syed Mukhtar-un- Nisar Andrabi
Assistant Professor,
Conservative Dentistry & Endodontics,
Dr. Z. A. Dental College, A. M. U. Aligarh.
 Lecture Outline
1) INTRODUCTION / DEFINITION
2) ROOT CANAL ANATOMY/ CONFIGURATION
1) ROOT CANAL MICROBIOLOGY
3) ROOT CANAL TREATMENT (Step by Step Procedure)
1) Indications
2) Contraindications
3) Access Opening
4) Shaping And Cleaning
5) Irrigation
6) Obturation
4) POST ENDODONTIC RESTORATIONS
5) CASE DESCRIPTIONS
Endodontics
The branch of dentistry that is concerned with the
morphology, physiology, and pathology of the
dental pulp and periradicular tissues.
Its study and practice encompass the basic and
clinical sciences, including biology of the normal
pulp; the etiology, diagnosis, prevention, and
treatment of diseases and injuries of the pulp; and
associated periradicular conditions.
(Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc.)
Tooth Anatomy
Root Canal System- 3D
Canal Configurations
Pulp and Periapical Disease

Oral microorganisms
The ultimate goal of the endodontic treatment
is either to prevent the development of apical
periodontitis or, in cases where the disease is
already present, to create adequate conditions
for periradicular tissue healing.

The rationale for endodontic treatment is to

eradicate the occurring infection and/or
prevent reinfection.
Microbiology of Root Canal
Infections
Endodontic
infections are
poly-microbial
“mixed type” of
infections.
Common Endodontic Pathogens
 Treponema denticola most commonly isolated from
 Porphyromonas endodontalis primary root canal infections

 Enterococcus faecalis (isolated from failed root canals)

 Bacteroidetes
 Streptococcus species
 Porphyromonas gingivalis
 Actinomyces radicidentis
 Candida albicans
Root canal treatment
Debridement
Disinfection
Obturation
Restoration (Post endodontic restoration)
When do we do root canal treatment?
INDICATION
Factors to be considered before endodontic
therapy?
1) General health of the patient
2) Strategic value of the tooth
3) Root canal anatomy of the tooth
4) Structural integrity of the tooth
5) Restorability of the tooth
6) Periodontal status of the tooth
When we don’t do root canal therapy?
CONTRAINDICATIONS
A non-strategic tooth
A tooth with insufficient periodontal support
A non-restorable tooth
A tooth with a vertical fracture
A tooth with massive internal or external resorption
A tooth that has a canal unsuitable for instrumentation or
surgery (e.g. dentinal sclerosis, sharp dilacerations etc.)
How do we do root canal therapy?
TREATMENT PROTOCOL
Step by step procedures:
Diagnosis
Preparation for the treatment
Endodontic access
Biomechanical preparation (Shaping & Cleaning)
Obturation
Post endodontic restoration
Diagnosis
1.Assemble facts
 Chief complaint
 Medical & Dental history Subjective sym.
 History of the present condition

2. Screen & interpret the assembled clues (Examination)

3. Differential Diagnosis

4. Operational or working diagnosis (Final diagnosis)

 Preparation for the Treatment
Infection Control.
Sterilization of the equipment
Personal barrier equipment
Follow CDC &OSHA guidelines
Informed Consent.
 The procedure and prognosis must be described.
 Alternatives to the recommended treatment must be presented, along with their
respective prognoses.
 Foreseeable risks and material risks must be described.
 Patients must have the opportunity to have questions answered

Local anesthesia administration.

Rubber dam isolation
Endodontic Access
 The objectives of access cavity
preparation:
1) To remove all caries,
2) To conserve sound tooth structure,
3) To completely unroof the pulp chamber,
4) To remove all coronal pulp tissue (vital or necrotic),
5) To locate all root canal orifices,
6) To achieve straight- or direct-line access to the apical foramen or to
the initial curvature of the canal, and
7) To establish restorative margins to minimize marginal leakage of the
restored tooth.
Phases of access cavity
preparation
Penetration phase
Enlargement phase
Finishing and flaring phase
Endodontic Access – armamentarium
 Orifice Location
Krasner and Rankow (J Endod 2004; 30(1):5)
a study involving 500 pulp chambers found that the
cementoenamel junction (CEJ) was the most important
anatomic landmark for determining the location of pulp
chambers and root canal orifices. study demonstrated the
existence of a specific and consistent anatomy of the pulp
chamber floor.
proposed nine guidelines, or laws, of pulp chamber anatomy
to help clinicians determine the number and location of
orifices on the chamber floor
 Orifice Location
Law of centrality: the floor of 1 2
the pulp chamber is always
located in the center of the
tooth at the level of the CEJ
(Figs. 1–3).
Law of concentricity: the walls
of the pulp chamber are always
concentric to the external
surface of the tooth at the level
of the CEJ (Figs. 1–3). 3
Law of the CEJ: the CEJ is the
most consistent, repeatable
landmark for locating the
position of the pulp chamber.
 Orifice Location
First law of symmetry: Except for the maxillary molars, canal orifices
are equidistant from a line drawn in a mesiodistal direction
through the centre of the pulp chamber floor.
Second law of symmetry: Except for the maxillary molars, canal
orifices lie on a line perpendicular to a line drawn in a mesiodistal
direction across the centre of the pulp chamber floor.
 Orifice Location
Law of color change: The pulp chamber floor is always darker in
color than the walls.
First law of orifice location:The orifices of the root canals are
always located at the junction of the walls and the floor.
Second law of orifice location: The orifices of the root canals
are always located at the angles in the floor–wall junction.
Third law of orifice location: The orifices of the root canals are
always located at the terminus of the roots’ developmental fusion
lines.
Law of color change 1st Law of Orifice Location

2nd Law of Orifice Location 3rd Law of Orifice Location

 How useful are the laws?
Knowledge of the law of centrality will help prevent crown
perforations in a lateral direction.
The law of concentricity will help the clinician to extend his
access properly.
The law of color change provides guidance to determine when
the access is complete. Proper access is complete only when the
entire pulp-chamber floor can be visualized.
The Law of Orifice Locations 1 and 2 can be used to identify
the number and position of the root canal orifices of the tooth
The laws of symmetry 1 and 2, color change, orifice locations 1
and 2 can be applied to any tooth.
Anterior Access Cavity Preparations
Anterior Access Cavity Preparations:

Inadequate access Correct refined

preparation. The access preparation
lingual shoulder with straight line
was access to the apical
not removed, and foramen
incisal extension is
incomplete. The file
has begun
to deviate from the
canal in the apical
region, creating a
ledge.
Mandibular
central/lateral
incisors
Posterior Access Cavity Preparations-
Maxillary molar
Posterior Access Cavity Preparations-
Maxillary first molar
Posterior Access Cavity Preparations-
Maxillary first molar
Posterior Access Cavity Preparations
Mandibular molar
 Shaping & Cleaning

Debridement & Disinfection

 Root Canal Therapy

Mechanical
Irrigation
Instrumentation

Intra-canal
medication

Microbial Control Phase

R.C. Filling
Biomechanical preparation-
(Shaping & Cleaning)
It is development of a logical cavity preparation that is
specific for the anatomy of each root(Raidenget et al JOE
1998)
Biomechanical preparation refers to the controlled
removal of dentin and root canal contents by
manipulation of root canal instruments and materials.
Shaping refers to specific root canal form with particular
design and objectives.
Cleaning refers to removal of all root canal contents
before and during shaping which includes substrates,
microflora, bacterial products, food, caries etc.
Objectives of Biomechanical
preparation
Biological Mechanical
 to eliminate  Develop Continuously
microorganisms from the tapering funnel from the
root canal system. access cavity to apical
foramen
 to remove pulp tissue
 The root canal preparation
that may support should maintain the path of
microbial growth, the original canal
 to avoid forcing debris  The apical foramen should
beyond the apical remain in its original
foramen which may position
sustain inflammation.  The apical opening should
be kept as small as practical
 Endodontic
instruments

Manually Engine-driven Ultrasonic

operated NiTi rotary instruments
instruments
K-files
Latch type rotary instruments
K-reamers
Reciprocating instruments
Headstroms
Self adjusting files
Broaches
Reamer

K-file
Techniques For Preparing Root Canals:
Apico coronal
 Standardized technique
 Step back
 Roane balanced force technique

Corono apical
 Step down
 Crown down pressure less
 Hybrid technique
Canal preparation-current protocol
Straight -line access
Canal exploration
Coronal pre-flaring/ pre-enlargement (orifice shaping)
Length determination
Apical third preparation.
Canal preparation-current protocol
Apical stop: Apical seat Open apex
Endodontic Irrigation
 Root Canal Irrigation
Rationale: Mechanical instrumentation leaves significant
portion of root canals wall untouched. (Peters et. Al 2001)
Irrigation solutions are required to eradicate microbiota,
Objectives Of Irrigation

(1) flushing out debris,

(2) lubricating the canal, mechanical objective
(3) tissue dissolving
(4) Antimicrobial action- biologic objective
 Most Commonly Used Irrigants

Hydrogen peroxide (3-30%)

Iodine potassium iodide (2-5%)

Sodium hypochlorite (0.5-5.25%)

Chlorhexidine (0.2-2%)

EDTA

Biopure MTAD
Factors Influencing Efficacy of
Irrigation
Diameter of the irrigating needle
Depth of the irrigating needle engaged in root canal
Size of enlarged root canal (radius of tube)
Viscosity of the irrigating solution (surface tension)
Velocity of the irrigating solution at the tip of the needle
Orientation of the bevel of the needle
Temperature
CFD Model of
Apical vapor lock
effect
 An effective irrigant must reach
the apex, create a current and
remove particles
Irrigation Accidents
Obturation
 Root Canal Obturation
Three-dimensional obturation of the radicular space is essential to
long-term success.
The canal system should be sealed apically, coronally, and laterally.
Obturation is a reflection of biomechanical preparation.
“canals poorly obturated are often poorly prepared and thus have a poor
prognosis”.
In 1924 Hatton indicated, “Perhaps there is no technical operation in
dentistry or surgery where so much depends on the conscientious adherence
to high ideals as that of pulp canal filling.”
 Timing of Obturation
Factors determining the readiness of a canal for
obturation:

Patient’s signs and symptoms

Ability to dry the canal
Timing of Obturation
In general, obturation can be performed after cleaning
and shaping procedures when the canal can be dried
and the patient is asymptomatic.
Obturation of a canal that cannot be dried
is contraindicated.
The Root Canal Filling
Core materials Sealers
 Silver Cones  Zinc Oxide and Eugenol
 Gutta-Percha  Calcium Hydroxide Sealers
(CRCS, Apexit and Apexit
 Activ GP Plus)
 Resilon  Glass Ionomer Sealers (Ketac-
Endo)
 Resin (AH-26, AH Plus,
EndoREZ, Epiphany)
 Silicone Sealers (RoekoSeal)
 Bioceramic
Size #30 standard gutta-percha
points exhibiting #.02, Activ GP
#.04, and #.06 tapers.

AH Plus sealer
The Ideal Root Canal Filling
Length,
Taper,
Density,
Level of gutta-percha and
sealer removal coronally
Adequate provisional
restoration
Lateral Compaction
Post Endodontic Restoration
Post Endodontic Restoration

Restoration of endodontically treated teeth is always a

challenge in many ways because of the various
differences in the physical properties of the vital and the
non-vital teeth.
Most often such teeth require the placement of posts and
core build ups to achieve proper resistance and retention
form.
How are endodontically treated teeth
different?
Altered physical characteristics:
 Moisture : Helfer et al
 Collagen: Rivera et al
 Access opening:
 14% reduction in strength

Altered esthetic characteristics

 Altered light refraction
 Degradation of pulp tissue
 Medicaments, fillings

Loss of proprioception
Treated cases
Pre-operative view of the patient.
Case 1
Pre- operative radiograph
Endodontic treatment started under rubber dam
isolation.
Post obturation radiograph
Post space preparation done
Fiber post cemented with dual cure resin
cement
Core build up done with light cure composite
resin.
Reduction done and Desired tissue retraction
achieved
PFM crown placed
Pre- and post treatment views
Case Report #2
Pre-operative View
Pre operative radiograph
Removal of the carious lesions
Insertion of the parapost and etching
of the remaining tooth portion
Core build up with composites
Tooth reduction done
PFM crowns placed
Pre- and post- t/t comparison
Post operative radiograph
Case
Case
Conclusion
The results of endodontic treatment are influenced by a
number of biological and technical factors like diagnosis, root
canal morphology, root canal instrumentation and
obturation, and complications during the treatment.
Optimum result in any case can be achieved through proper
diagnosis, prompt treatment planning and due consideration
towards restoration of involved tooth to its proper form and
function.
Our treatment decisions must be governed by the best
available evidence i.e “Evidence Based Practice”.